one-stage repair of aortic coarctation & intracardiac defects
DESCRIPTION
One-Stage Repair of Aortic Coarctation & Intracardiac Defects. Yong Jin Kim, M.D. Department of Thoracic & Cardiovascular Surgery Seoul National University Hospital Seoul, Korea. Morphology of Coarctation. Repair of CoA with Intracardiac Defects. Controversies still exist - PowerPoint PPT PresentationTRANSCRIPT
CoA
SNU Children’s Hospital
Yong Jin Kim, M.D.
Department of Thoracic & Cardiovascular SurgerySeoul National University Hospital
Seoul, Korea
One-Stage Repair of Aortic Coarctation & Intracardiac Defects
CoA
SNU Children’s Hospital
Morphology of Coarctation
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SNU Children’s Hospital
Repair of CoA with Intracardiac Defects
• Controversies still exist
about optimal surgical treatment
• Methods of repair– Coarctation repair alone– Coarctation repair with PA banding– One-stage repair of associated defects
CoA
SNU Children’s Hospital
Advantages of One-stage Repair
• Avoid complications of longstanding disease
• Benefits in the perioperative period
– Ease of repair in arch hypoplasia
– Lower recurrence rate
– Benefits for complete anatomic repair
• Overall wellbeing in the future development
CoA
SNU Children’s Hospital
One-Stage Repair of CoA with Associated Defects
• The time of CPB, TCA, ACC
• Relief of LVOT obstruction
• Residual diseases– Residual coarctation– Residual subaortic stenosis– Residual intracardiac defects
CoA
SNU Children’s Hospital
Subaortic Stenosis in Coarctation
• Reasons of underestimation– Presence of nonrestrictive VSD
– Aortic arch obstruction
– Hemodynamic status
• Criteria by anatomic measurement– Diastolic ratio of descending aorta to LVOT
below 1.0 is indicative , severe below 0.6
– LVOT value less than 4-5 mm in neonate
CoA
SNU Children’s Hospital
Surgical Technique of Aortic Arch Reconstruction
• Wide mobilization of aorta & arch vessels
• Careful trimming of all the ductal tissue
• Elimination of anastomosis to the isthmus
beyond the left subclavian artery
• Extended end-to-end or side anastomosis
proximal to arch hypoplasia
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SNU Children’s Hospital
Operative ProcedureExtended end-to-end anastomosis
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SNU Children’s Hospital
Operative ProcedureExtended end-to-side anastomosis
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SNU Children’s Hospital
Experience of One-stage Repair
Seoul National University Children’s Hospital
SNU Children’s Hospital
CoA
Purpose
• To evaluate the effectiveness of surgical treatment – mortality, morbidity and outcome– 66 patients who underwent one-stage transsternal
repair of coarctation and associated defects.
CoA
SNU Children’s Hospital
Duration : Sept. 1989 - Dec. 1999
Number : 66 patients
Sex : 40 male, 26 female
Age : 67 ± 82 d ( 5 d - 530 d )
Bwt (kg) : 4.1 ± 0.2 Kg (1.8 - 9.8 Kg)
Patient Profiles
SNU Children’s Hospital
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Distribution
Type of lesion No. of No. of patient tubular hypoplasia
Group 1 CoA, minor defects 8 ( 12.1%) 1 (12 %)Group 2 CoA, VSD* 46 ( 69.7%) 33 (72 %)Group 3 CoA, complicated defects 12 ( 18.2%) 6 (50 %)
Total 66 (100 %) 40 (61 %)
CoA
SNU Children’s Hospital
Associated Anomaliesin CoA with minor defects (n=8)
• ASD + PDA
5
• Anomalous origin of RPA + PDA 2
• ASD + AS (bicuspid AV)
1
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SNU Children’s Hospital
Associated Anomaliesin CoA with VSD (n=46)
• PDA 42
• ASD 18
• Aortic stenosis 2
• Coronary artery anomaly 1
• Tricuspid valve straddling 1
• Congenital tracheal stenosis 1
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SNU Children’s Hospital
Types of Isolated VSD
Type of VSD No. of
patients
Perimembranous 28
with extension 14
with posterior malalignment 14 (6)*
Subarterial 17
with subaortic stenosis 3 (3)*
Multiple 1* Enlargement of VSD, resection of conal septum was done
n=46
SNU Children’s Hospital
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Associated Anomaliesin CoA with complicated defects (n=12)
TOF 2 Shone’s syndrome 2
– Parachute MV + SAS + supravalvular AS 1
– MSR + AS(bicuspid) 1
TGA with VSD 2 DORV with subaortic VSD 1 Single atrium, VSD, systemic venous anomaly 1 Lt SVC with unroofed CS, AS, VSD 2 HLHS 2
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SNU Children’s Hospital
Surgical Methods (1)
Operative technique : simultaneous repair of CoA &
associated defects through the transsternal approach
Conduction of CPB
– Intermittent cold crystalloid or blood cardioplegia
– Deep hypothermic circulatory arrest
– CPB time (min) : 131 ± 38 (86 - 335)
– ACC time (min) : 60 ± 16 (21 - 117)
– TCA time (min) : 37 ± 14 (20 - 72)
SNU Children’s Hospital
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Type of operation No. of patient
Patch angioplasty 5 ( 7.6%)
R & A* 12 (18.2%)
ERAA** 49 (74.2%)
Total 66
* R & A = resection & anastomosis** ERAA = extended end-to-end anastomosis
Surgical Methods (2)
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SNU Children’s Hospital
Mortality
Group early death late death
Gr 1 (n= 8) 0 1Gr 2 (n=46) 5 ( 10.8 %) 1Gr 3 (n=12) 2 ( 16.7 %) 2
Total (n=66) 7 ( 10.6 %) 4
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SNU Children’s Hospital
Causes of Early Death
Pneumonia, sepsis, multiorgan failure (POD #20)
Remaining AS & AR, LCO (POD # 8)
Residual SAS, myocardial failure (POD # 1)
Myocardial failure, Pulm. HT (POD # 1)
Myocardial failure, residual SAS (POD # 1)
Afterload mismatch, LV failure, Pulm. HT (POD # 0)
Mediastinitis, sepsis (POD #11)
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SNU Children’s Hospital
Actuarial Survival Rate
Months
140120100806040200
Cum
ula
tive S
urv
ival
1.00
.90
.80
.70
Survival Function
Censored
96.6%94.7%
92.9%
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SNU Children’s Hospital
Complications
Complication No.of patient
Diaphragmatic palsy 4Hypoxic encephalopathy 3Pneumonia 3Transient seizure 2Arrhythmia 3Mediastinitis 2Chylothorax 2Pericardial effusion 2
n= 66
Risk Factors for Hospital Mortality
Variables Group Mean or Mortality p-Value
Age at Op. survivor 76 ± 88d± 88d 0.055
mortality 28 ± 19dACC survivor 59 ± 17min
mortality 67 ± 22min
SAS (+) 2/ 8 25.0% 0.877
(-) 9/58 15.5%
Complicated defects (+) 4/14 28.6% 0.552
(-) 7/52 13.5%
Arch hypoplasia (+) 7/40 17.5% 0.496
(-) 4/26 15.4%
SNU Children’s Hospital
SNU Children’s Hospital
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Follow-up Results (1)
Follow-up– Total 59 patients– Duration (mo) : 30.4 ± 33.5 ( 8 - 127 )
Late death (4 / 59 survivors, 6.8%)– Asphyxia during seizure, respiratory failure– CHF, febrile seizure, respiratory failure – Intestinal strangulation (malrotation)– Pneumonia
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SNU Children’s Hospital
Follow-up Results (2)
Residual coarctation (2/55, 3%)– Color Doppler (> v = 2.25m/s), Pr gradient (>20mmHg)
– Two, borderline degree (interval 12, 32mo)
No additional procedure
Reoperation (2/55, 3%)– Konno operation due to recurrent subaortic stenosis (inter
val 44mo)
– Permanent pacemaker insertion due to heart block (interval 7 years)
SNU Children’s Hospital
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Conclusions
One-stage transsternal repair of aortic coarctation & cardiac
defects is a good surgical option in selected cases.
This approach may be applicable to following conditions ;
– Patients with little benefits from relief of CoA alone.
– Size & type of VSD, unlikely to close spontaneously.
– CoA with minor, major associated defects repaired.
– CoA with severe hypoplasia of aortic arch.